Va form 21 0779-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section I - Identification Information. Fill in the name and address of the nursing home, along with the claimant's first name, middle initial, last name, social security number, and VA file number.
3. Proceed to Section II - Nursing Home Information. This section must be completed by a nursing home official. Enter the date admitted to the nursing home and when Medicaid began.
4. Indicate the amount the patient is responsible for out of pocket. Ensure accuracy as this information is crucial for processing claims.
5. Select whether the claimant is receiving skilled or intermediate nursing care by checking the appropriate box.
6. The nursing home official should then provide their name, title, office telephone number, sign, and date the form was signed.

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